Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology

The OB/GYN profession cares for women who are pregnant, during the prenatal, delivery and postnatal stages of pregnancy. Also treats diseases and provides routine physical care of the female reproductive system.



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Spontaneous Vaginal Delivery
Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.

Spontaneous Vaginal Delivery - 1
Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.

Suction, Dilation, & Curettage
Missed abortion. Suction, dilation, and curettage.

Suction, Dilation, & Curettage - 1
Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.

TAH - Discharge Summary
Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.

TAH & BSO
Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

TAH & Salpingooophorectomy
Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.

TAH & Salpingo-oophorectomy
Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.

TAH & Salpingo-oophorectomy - 1
Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.

TAH & Salpingo-oophorectomy & Lysis of Adhesions
Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples